Facility Evaluation Report

On 4/5/24 (LPA) Javina George made an attempted visit, for the purpose of conducting the facilities 1 year required visit. There was no one at the home at the time of the attempt, and the inspection could not be conducted. On today's date 4/24/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility and was able to conduct the facility's 1 year required visit. LPA was greeted and granted entry by Assistant Administrator Julita Ramirez, where LPA explained the purpose of the visit. At the time of the visit there were zero (0) resident's present as they were all at the day program. All staff present were observed to have obtained criminal record clearance and were associated to the facility.

LPA conducted a tour of interior and exterior of the facility. The facility is a single story home consisting of five (5) bedrooms and three (3) bathrooms. LPA observed for there to be construction workers on the premises. The facility is currently undergoing renovations room by room. The renovations include upgrading the bathrooms, painting, replacing closet doors and repairs of chips and discoloration. The renovations are expected to be completed within the next six (6) months.

The facility was observed to have one fully charged fire extinguisher. The smoke and carbon monoxide detectors were tested and were observed to be operable. The emergency disaster drills are conducted on a quarterly basis and the last drill was conducted on 4/1/24. The medications are locked in cabinet located in the hallway. The chemicals and sharp objects are locked in the cabinet underneath the kitchen sink. There are no pools or bodies of water observed on grounds. There are no known guns or ammunition on the premises. The hot water was tested and was found to be within regulatory limits measuring 109.7-111.2 degrees F.

LPA conducted a review of both staff and resident files. The resident files had the required documentation such as admission agreements, Individual Program Plan (IPP), or appraisal needs and services plan, and medical assessment. P&I funds were reviewed for 2 of 5 residents and all money was present and accounted for.